The primary care physician and the treatment of patients with skin disorders

Scientific advances have altered the nature of primary care medicine. Primary care providers are increasingly asked to care for a broad spectrum of common maladies, including cutaneous disease. We review studies that have compared primary care physicians with dermatologists with respect to the diagnosis and treatment of skin disorders. Though primary care providers play a crucial role in the delivery of health care, the judicious and appropriate use of dermatology consultation should be encouraged.     

Developing ambulatory care physician performance measures

Major US corporations and consumer groups are demanding more accountability for their health care expenditures. In response, the federal government, specialty boards, and state medical boards are evaluating ways to implement objective measures of quality. Many dermatologists already choose to participate in quality measurement and improvement activities. More will need to, as recertification and relicensure requirements change. Dermatologists need measures that are specialty-specific, as measures developed for primary care physicians are generally not appropriate for a dermatologic practice.     

Primary care physician attitudes regarding sexually transmitted diseases

BACKGROUND: Primary care physicians see the majority of patients with sexually transmitted diseases (STDs), but little is known about their attitudes regarding STD-related issues. GOAL: The study goal was to determine the attitudes of primary care physicians toward STD-related issues, to determine physicians' characteristics associated with attitudes, and to examine the relationship of attitudes to STD counseling practices. STUDY DESIGN: A cross-sectional survey was mailed to randomly selected primary care physicians in Pennsylvania. RESULTS: Of 1054 eligible physicians, 541 (51%) responded. Although most physicians were comfortable discussing sex-related issues with their patients (89%), many believed their STD counseling was ineffective (70%), their medical school STD training was inadequate (48%), or that they were not responsible for STD preventive services for their patients (43%). Overall, STD-related attitudes were more positive among physicians who were female, worked in clinic settings, and received adequate training in STDs. More positive attitude scores were significantly associated with performance of six specific risk-assessment and counseling behaviors. CONCLUSIONS: Many physicians reported low confidence, limited responsibility, and time barriers that may affect their STD-prevention practices. Interventions that influence STD-related attitudes may improve STD-prevention practices by primary care physicians.     

The emerging role of physician assistants in the delivery of dermatologic health care

The NAMCS provides a wealth of information on use of PAs in all practices, including dermatology. Two important points regarding the NAMCS and SDPA data are addressed here: the number of visits to PAs for dermatologic symptoms and the expected growth of PA use in dermatologists' offices. Dermatologic symptoms were evaluated frequently by PAs, accounting for 14% of PA visits. These statistics do not address the number of referrals those PAs made to dermatologists. Perhaps PAs as a group should be targeted for increased dermatologic education, particularly stressing the need for appropriate referral to a dermatologist. PAs could increase the number of dermatology referrals from primary care offices with improved understanding of the importance of the dermatologist in the management of patients' overall skin health. At projected growth rates, the number of PAs employed by dermatologists should exceed 500 by the end of 2000. Most of this growth has been in private practices and rarely in HMOs or in large multispecialty clinics. There are a number of reasons for this growth, as follows: A PA may help reduce the patient load on the dermatologist, especially with sameday appointments and drop-ins. Some dermatologists are moving away from clinical dermatology into cosmetics, which not only leaves a vacuum in clinical dermatology, but also creates job opportunities for PAs in cosmetic dermatology. Regarding managed care growth, PAs can have a positive impact on the problem of having to see more patients for less money. PAs are cost-effective. In the 1998 SDPA survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:1. Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. PAs can cover satellite offices, allowing for practice expansion. Effective with the new Medicare laws of January 1, 1998, PAs can now see new Medicare patients or Medicare patients with new conditions without the physician being on site, opening up the possibility for satellite offices in remote areas. Just as dermatologists may move toward specialization in surgery, cosmetics, or medical dermatology, PAs may do the same, filling a niche in a particular practice. As in other specialties, patient acceptance of seeing dermatology PAs has not been a significant problem. Continued access to the dermatologist remains unfettered, but, over time, many patients become willing to see either. Are PAs likely to become future competitors of dermatologists? Genuinely concerned dermatologists worry that a dermatology-trained PA will become part of a gatekeeper system that impedes patient access to dermatologists. This is not happening and is not at all likely to become a trend, for a number of reasons. First, primary care cannot compete with dermatology practices in remuneration for PAs. Just as financial benefits in high-production specialty practices entice physicians, the same benefits entice PAs as well. Second, according to member surveys of the SDPA, virtually 100% of fellow members work with dermatologists. Although PAs can work in any type of practice and evaluate dermatologic symptoms just as a general practitioner would, PAs who specialize in dermatology primarily practice with dermatologists, a collegial association most PAs seek out. PAs have steadfastly maintained their dependent, noncompetitive relationship with physicians and would not have it any other way. Although PAs see a good number of patients (2.8 million) with dermatologic symptoms, the NAMCS data indicate that most (72%) of these patients are also seen by a physician. Third, physicians are ultimately responsible for the actions of their PA employee. A general practitioner not trained to perform excisions or manage certain dermatologic conditions should not allow a PA to perform such duties. Similar to much of medicine, the PA profession continues to evolve, with many members moving awa     

Specialized dermatological care for marginalized populations and education at the primary care level: is community dermatology a feasible proposal?

Skin diseases have a very high frequency either in developed as well as in undeveloped countries. Guerrero, Chiapas, and Oaxaca are the most impoverished states in Mexico, where 24% of the population lacks basic health care, and only 15% are estimated to have access to specialists. Community Dermatology program was founded in 1991 with the intention of improving the dermatological health of remote, marginalized inhabitants of the state of Guerrero. The program consists of a two‐day visit to a pre‐selected community; the first day includes a basic dermatology training course for local providers, and day 2 is a “Jornada”, which means a day of free medical consultation and treatment. Pityriasis albus Cloasma, vitiligo, and acne continue to be the most frequent diagnosed primary disorders, as in rural areas occupational obligations include prolonged sun exposure. The experience and success of Community Dermatology over the last 20 years has demonstrated that this model of healthcare delivery and instruction is economically feasible, provides practical and quantifiable benefits for the communities served, and could be emulated by other disciplines within medicine.     

Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care

Background Cellulitis is responsible for over 400 000 bed days per year in the English National Health Service (NHS) at the cost of £96 million. Objectives An audit following transfer of care of lower limb cellulitis managed in secondary care from general physicians to dermatologists. Methods Review of patient details and work diaries from the first 40 months of implementation of the new model of care. Results Of 635 patients referred with lower limb cellulitis 33% had other diagnoses which did not require admission. Four hundred and seven of 425 patients with cellulitis were managed entirely as outpatients, many at home. Twenty‐eight per cent of patients with cellulitis had an underlying skin disease identified and treated, which is likely to have reduced the risk of recurrent cellulitis, leg ulceration and lymphoedema. Only 18 of 635 patients referred with lower limb cellulitis required hospital admission for conventional treatment. Conclusions This new way of managing suspected lower limb cellulitis offered substantial savings for the NHS, and benefits of early and accurate diagnosis with correct home treatment for patients.     

The primary care provider and the care of skin disease: the patient's perspective

OBJECTIVE: To ascertain the patient's perspective on dermatologic care provided by primary care providers (PCPs) or dermatologists. DESIGN: Cross-sectional survey of patients drawn from primary care and dermatology clinics. SETTING: Academic Veterans Affairs medical center. PATIENTS: Convenience sample of patients in either a primary care or a dermatology clinic. INTERVENTION: Survey questionnaire. MAIN OUTCOME MEASURES: Patients' confidence in having their skin problems cared for by PCPs and dermatologists and satisfaction with previous care rendered. RESULTS: A total of 137 patients in the primary care clinic (group 1) and 100 patients in the dermatology clinic (group 2) participated. Patients (N = 237) expressed confidence in their PCP's ability to treat rashes (62%), diagnose skin cancer (65%), perform skin biopsies (60%), "freeze" lesions with liquid nitrogen (50%), and perform cutaneous surgery (46%). Group 2 patients were significantly less likely to have confidence in their PCP than group 1 patients for all measures other than the use of liquid nitrogen. High levels of confidence were expressed in a dermatologist's ability for all 5 measures: 92%, 91%, 92%, 83%, and 85%, respectively. Patients were more confident in dermatologists' abilities to perform these procedures compared with PCPs (P<.001 for all comparisons). Of patients previously treated for skin disorders, there was a high rate of satisfaction with the treatment rendered by PCPs (81% for group 1 and 75% for group 2) and by dermatologists (92% for group 1 and 90% for group 2). However, patient satisfaction was higher for dermatology vs primary care for the treatment of skin disease (P<.001). Direct access to dermatologists was preferred. CONCLUSIONS: Although patients have confidence in their PCP to care for their skin disease, they have greater confidence in the care provided by dermatologists. Among patients previously treated for skin disease, satisfaction was higher with care rendered by dermatologists vs PCPs. Most patients prefer direct access to dermatologists should they develop a skin problem.     

Integration of the leprosy programme into primary health care: a case study of perceptions of primary health care workers

Integration of the vertical leprosy programme into the existing horizontal health programme poses various administrative and operational challenges to programmers. In order to understand the preparedness of the PHC workers for integration of leprosy into primary health care services, 71 PHC workers were interviewed using a structured interview schedule. The results showed that about 42% of the staff have heard of the concept of integration earlier and 90% of the PHC staff are willing to treat leprosy patients in the primary health care centre, but only 72% were in favour of integration. The reasons for favouring integration were (1) wider coverage with MDT, (2) frequent field visits by the worker, (3) better rapport with the community, (4) timely treatment and (5) cost-effectiveness. About 28% of the staff members did not favour integration for the reasons that the leprosy programme would suffer, targets cannot be met, supervision would be difficult, knowledge of the staff was inadequate and importance cannot be given to leprosy as family planning is always a priority in PHC centres. About 43% of the staff felt that the performance of the leprosy programme would be better after integration. With regard to workload, 60% of the sample felt that there would be increase in the workload in the field, record maintenance and supervision. The difficulties foreseen by the workers were grouped into 6 categories, viz., administrative, managerial, technical, personnel, social and miscellaneous. It is worth noting that 91% of the staff that included all categories said they were not afraid of leprosy, but needed training in leprosy work. About 50% of the staff expected increase in salaries and promotions if integration took place.     

When the goal is palliative care

OBJECTIVE: An analysis of the literature regarding palliative care of patients with wounds. DATA SOURCES: Health care literature, including national and international reports, focusing on enhancing quality of life for individuals with wounds who are receiving palliative care. CONCLUSION: The literature on palliative care of patients with wounds is limited. Integration of palliative care concepts and chronic wound management is challenging; however, palliative care, which focuses on comfort and symptom management for quality of life, can provide the best quality care within the parameters of disease and individual patient wishes.     

Shared care in the management of genital Chlamydia trachomatis infection in primary care

OBJECTIVES: To investigate the impact of a health adviser in genitourinary medicine as a training and support resource on the management of Chlamydia trachomatis in a large inner city health centre. METHODS: A large, inner city health centre was selected at random for the intervention, with another selected as control. The health adviser offered support and training in the management of C trachomatis to clinical staff in the intervention health centre for 6 months. Data on testing activity were collected over the period of the intervention and during the equivalent period in the previous year. Data on partner notification activities were collected from case notes. RESULTS: The research intervention was effective in increasing C trachomatis testing activity. However, the majority of tests were offered to women over 20 years of age and no increase in the proportion of positive results was observed. CONCLUSIONS: The intervention was effective in increasing C trachomatis testing activity, but did not improve the overall detection rate. Health centre staff accommodated opportunistic testing for C trachomatis into existing healthcare practices, as opposed to introducing new screening systems designed to reach the target population.     

Erectile dysfunction is a signal of risk for significant medical comorbidities: A primary care view

Erectile dysfunction (ED) is a multisystemic disorder most commonly caused by vascular insufficiency. Because the organic etiologies that cause ED often impact concurrently on other body systems, multiple comorbidities have been noted that occur more frequently among men with ED than among men without ED. This encourages us to consider the presence of ED as a signal of a variety of disorders that have similar etiologies, including psychosocial problems, endocrine imbalances, neurologic disorders, and, most notably, cardiovascular risk factors and/or disease. Evidence is accumulating that ED, especially vasculogenic ED, is a signal for endothelial dysfunction and resultant cardiovascular disease risk. ED may also be a "harbinger" of symptomatic cardiovascular or neurologic diseases. Knowing that a man has ED should encourage further evaluation for these comorbidities, because early detection may allow attenuation of disease risk or actual disease. The best way to perform this evaluation in men with ED needs further study. The role of the presence of ED as a “screening test” for increased cardiovascular disease risk also needs further exploration.